ICD Code N40.1

ICD code N40.1 is used to identify a medical condition known as benign prostatic hyperplasia (BPH) with associated lower urinary tract symptoms (LUTS). This condition involves the non-cancerous enlargement of the prostate gland, which can lead to urinary issues such as difficulty in starting urination, a weak urine stream, frequent urination, or the feeling of incomplete bladder emptying. This code is crucial for healthcare providers to accurately document and manage the treatment of patients experiencing these symptoms, ensuring proper billing and reimbursement processes within the healthcare revenue cycle.

1. Frequent Urination: Increased frequency of urination, especially noticeable during the night (nocturia), is a common symptom that may warrant the use of this ICD code.

2. Urgency to Urinate: A sudden, strong urge to urinate that is difficult to delay can be indicative of the condition associated with this code.

3. Weak Urine Stream: A noticeable decrease in the strength or force of the urine stream is a diagnostic criterion for using this code.

4. Difficulty Starting Urination: Hesitancy or difficulty in initiating the flow of urine is a symptom that aligns with the use of this ICD code.

5. Incomplete Bladder Emptying: A sensation that the bladder is not completely empty after urination is a key symptom.

6. Straining to Urinate: The need to exert effort or strain to begin urination is another diagnostic criterion.

7. Intermittent Urine Flow: Experiencing a stop-start flow of urine during urination can be a symptom associated with this code.

8. Post-Void Dribbling: Dribbling of urine after completing urination is a symptom that may necessitate the use of this ICD code.

9. Urinary Retention: Inability to completely empty the bladder, leading to retention of urine, is a significant diagnostic criterion.

10. Recurrent Urinary Tract Infections (UTIs): Frequent UTIs due to incomplete bladder emptying may also be a reason to use this ICD code.

For the ICD code N40.1, which pertains to benign prostatic hyperplasia with lower urinary tract symptoms, the relevant CPT codes that may be applicable include:

1. 52000 - Cystourethroscopy (separate procedure)

2. 52601 - Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)

3. 52648 - Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed)

4. 53850 - Transurethral destruction of prostate tissue; by microwave thermotherapy

5. 53852 - Transurethral destruction of prostate tissue; by radiofrequency thermotherapy

These CPT codes are commonly associated with procedures that may be performed to treat conditions related to the ICD code N40.1. It is important for healthcare providers to verify the specific procedures and services rendered to ensure accurate coding and billing.

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